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<br /> CITY OF EV�R�TT!'ERM1T SERVICES
<br /> 3200 C�[]AR STR��T, EVER�TT,WA 982D'�
<br /> (P}A�25�257-88'f 0 � FAX 425-257-8857 j (�)everetteps@everettwa.gov� www.averettwa.govlpermits
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<br /> A120JECTADDRESS: '
<br /> �UILDIN�AR�A(if residentiaf,new constructian,temal 1,or addition� S� ' ;
<br /> BLJILDINGTYPE: Cl SFR D�Ti4C1-t�D Cl SFRATTACH�b ❑bUf'L�X Cl NEULTI-�AkNILY-#OF UNITS;, �GQIVIMEFZCtAL. fi
<br /> USE 0�BL31LDI1VG. Q� (y E��1L� f 1 • -'
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<br /> C�NTCiA,CT PR[CE OF WORK:$ � ;
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<br /> NLIMB�t�QF DEVECES if low�olta e :• ;
<br /> ' �IRE AL.ARM? ❑YES NO ;
<br /> AS�OCfAT�D B�1lE.D1NG PERMiT# if a pllcable:
<br /> D�SCR[1'TlC3N OF WORK: !
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<br /> OWN�R NAM�: � TENANT NAM� it Commercial:
<br /> � OWuER MAi�.INGAAARES5: sra�r �7QX � � � '
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<br /> OWNER PNONE: . OWNER�MAII.:
<br /> CONTRACTO.Ft.NAME: � �J /�✓
<br /> CpNTRACTOR AbDRESS: STREET Pa f3px
<br /> CFIY � IG 37AlEV�/�I 2fP � �
<br /> �ONTR4CTOR PHON�: 'fj"� �"�J � Cp�V7'RAC70R�MAII,. � . I��1� I I�, �� .
<br /> GON'FFtACTOFt LtC.#(REQUIRF�]: ��N� �L�z GITY O��11�I2�TT�USi1�i�5S LIC.#(R�QUIR�D):�O
<br /> PRIMAk?Y GONTACT: L�OWN�R� k�CONTRACi'OR ❑OTHER{piease Speci€y) •
<br /> GON7'ACTNAM�: CONTAGTPHON�: �(J�g-73(��-lpS��p
<br /> � �L!JijI�J S ��D�IV CqNTAGT�MAIL.: D� !�1S.L�.KD�t/� J�l�"W 1 T, G�.otY►
<br /> AGJ�EEMENT.•7'hereby cerf!!y that!have read and exam/ned th/s appkcafibn andlcnow the sams ta 6e frue end correc� A►/provisloas oflaw,s and ard/nances governing thts
<br /> type of work wlltbe`completed whatherspaclfied here/n ornot The grantrng oPa permlt does not presume tn gtve euthor/fyto vlafafe orcance!fhe provlsPons of any attrersiate or
<br /> local/aw regutating canstructlon or fhe perinrmance ot conslrucflon. Thaf f am aofhamed by the awnarofthis propetty to pe�form the work for whlch apprcaflon Is made and!
<br /> comply vYlfh ihe Stafe Confractors Law t8.27 RCtNarzd 29�20o WAG
<br /> Cify ofEvarett Officla!Use Onty
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<br /> ownerlAu or zed AgentSignaEura Dafe (Rsvlsed 10/92/2096) ',
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